India shows the way in putting routine childhood immunization back on track

Lakshmana Venkat Kuchi *

The Covid-19 pandemic has left behind an alarming phenomenon of a huge number of newborn children going without regular vaccinations. What this means is that hundreds of thousands of children in the world are at risk of catching life-threatening and life-taking serious but preventable ailments.

According to the WHO and UNICEF, which recorded official data of vaccinations, the largest sustained decline in childhood vaccinations in 30 years has been recorded between 2019 and 2021, when the world went through the pandemic and its killer waves that brought the global economic activity to a near standstill as well.

According to the latest data, the percentage of children who received three doses of the vaccine against diphtheria, tetanus, and pertussis (DTP3) – a marker for immunization coverage within and across countries – fell 5 percentage points between 2019 and 2021 to 81 per cent.

Which means, 25 million children missed out on one or more doses of DTP through routine immunization services in 2021 alone. This is 2 million more than those who missed out in 2020 and 6 million more than in 2019, highlighting the growing number of children at risk from devastating but preventable diseases.

Reasons for this vary, but increased misinformation and COVID-19 related issues such as service and supply chain disruptions, resource diversion to response efforts, and containment measures that limited immunization service access and availability can be held responsible for the infants missing routine inoculations.

The numbers are scary.

18 million of the 25 million children did not receive a single dose of DTP during the year, the vast majority of whom live in low- and middle-income countries, with India, Nigeria, Indonesia, Ethiopia, and the Philippines recording the highest numbers.

For us in India too, the Covid-19 pandemic adversely affected the progress towards reducing the number of Zero-dose (children with no vaccination). According to WHO and UNICEF estimates, the number of children who did not receive the first dose of the DTP-1 vaccine in India increased to 3 million in 2020 from 1.4 million in 2019.

But India quickly redoubled efforts and despite having the largest birth cohort in the world, India managed to prevent further backslide with catchup programmes such as the Intensified Mission Indradhanush (IMI) 3. This enabled India to bring down the figure to 2.7 million in 2021.

Aiming to immunize every pregnant woman and child, the Government of India launched IMI 4.0 in February 2022, which is the largest vaccination drive globally reaching out to missed children and pregnant women.

Every year, India vaccinates more than 30 million pregnant women and 27 million children through the Universal Immunization Programme. Praise for India’s success came from UNICEF that noted “India successfully managed to prevent a decline in coverage, while ensuring a continued focus on COVID-19 vaccination.”

A rapid resumption of routine immunization services coupled with evidence based catch-up campaigns enabled India to prevent a backslide on routine immunization coverages.

Globally, it was hoped that 2021 would be a year of recovery during which strained immunization programmes would rebuild and the cohort of children missed in 2020 would be caught-up. Instead, DTP3 coverage was set back to its lowest level since 2008 which, along with declines in coverage for other basic vaccines, pushed the world off-track to meet global goals, including the immunization indicator for the Sustainable Development Goals.

This historic backsliding in rates of immunization is happening against a backdrop of rapidly rising rates of severe acute malnutrition. A malnourished child already has weakened immunity and missed vaccinations can mean common childhood illnesses quickly become lethal to them. The convergence of a hunger crisis with a growing immunization gap threatens to create the conditions for a child survival crisis.

Vaccine coverage dropped in every region, with the East Asia and Pacific region recording the steepest reversal in DTP3 coverage, falling nine percentage points in just two years. The world now requires monumental efforts to reach universal levels of coverage and to prevent outbreaks.

Inadequate coverage levels have already resulted in avoidable outbreaks of measles and polio in the past 12 months, underscoring the vital role of immunization in keeping children, adolescents, adults, and societies healthy.

First dose measles coverage dropped to 81 per cent in 2021, also the lowest level since 2008. This meant 24.7 million children missed their first measles dose in 2021, 5.3 million more than in 2019. A further 14.7 million did not receive their needed second dose. Similarly, compared to 2019, 6.7 million more children missed the third dose of polio vaccine and 3.5 million missed the first dose of the HPV vaccine- which protects girls against cervical cancer later in life.

WHO and UNICEF are working with Gavi, the Vaccine Alliance and other partners to deliver the global Immunization Agenda 2030 (IA2030), a strategy for all countries and relevant global partners to achieve set goals on preventing diseases through immunization and delivering vaccines to everyone, everywhere, at every age ?

The priority of the Alliance must be to help countries to maintain, restore and strengthen routine immunization alongside executing ambitious COVID-19 vaccination plans, not just through vaccines but also tailored structural support for the health systems that will administer them.

The prescription for successful catch-up vaccination is to step up routine immunization and expansion of outreach services underserved areas to reach missed children and implement campaigns to prevent outbreaks. Implementing evidence-based, people-centered, and tailored strategies to build trust in vaccines and immunization, counter misinformation and increase vaccine uptake particularly among vulnerable communities are key to improve the quality and efficacy of the vaccination programme.

At the same time, ensuring current pandemic preparedness and response and the global health architecture strengthening efforts be taken up, which also need investment in primary health care.

But all these would be possible, if and only if, there is political commitment from the governments. Once the backing is secured, the need is to prioritize strengthening health information and disease surveillance systems to provide the data and monitoring.

Leveraging and increasing investments in research to develop and improve new and existing vaccines and immunization services that can achieve community needs and deliver on IA2030 goals is the need of the hour.